Apparatus and method for guide-wire based advancement of an adjustable implant

ABSTRACT

A tissue-engaging element has a distal portion configured to engage a portion of tissue of the heart. A guide member is reversibly coupled to the tissue-engaging element. An artificial chorda tendinea has a distal end and a proximal end, at least the distal end being slidably coupled to the guide member. A tool is slidable along the guide member distally toward the tissue-engaging element while (i) the tool is coupled to at least the distal end of the chorda tendinea, and (ii) the guide member is coupled to the tissue-engaging element, such that sliding of the tool along the guide member distally toward the tissue-engaging element while (i) the tool is coupled to at least the distal end of the chorda tendinea, and (ii) the guide member is coupled to the tissue-engaging element, slides at least the distal end of the chorda tendinea toward the tissue-engaging element.

CROSS-REFERENCES TO RELATED APPLICATIONS

The present application is a Divisional of U.S. Ser. No. 14/937,233 to Reich et al., which published as US 2016/0058557, and which is a continuation of U.S. Ser. No. 13/707,013 to Reich et al., (now U.S. Pat. No. 9,180,007), which is a continuation-in-part of:

a. International Application PCT/IL2011/000446 to Miller et al., entitled “Apparatus and method for guide-wire based advancement of a rotation assembly,” filed on Jun. 6, 2011 (which published as WO/2011/154942);

b. U.S. patent application Ser. No. 12/795,192 to Miller et al., entitled “A method for guide-wire based advancement of a rotation assembly,” filed on Jun. 7, 2010 (which published as US 2011/0301698) (now U.S. Pat. No. 8,690,939); and

c. U.S. patent application Ser. No. 12/795,026 to Miller et al., entitled “Apparatus for guide-wire based advancement of a rotation assembly,” filed on Jun. 7, 2010 (which published as US 2011/0106245, now U.S. Pat. No. 8,940,042), which is a continuation-in-part of U.S. patent application Ser. No. 12/608,316 to Miller et al., entitled, “Tissue anchor for annuloplasty device,” filed on October 29, 2009 (now U.S. Pat. No. 8,277,502).

All of these applications are incorporated herein by reference.

FIELD OF THE INVENTION

The present invention relates in general to valve and chordeae tendineae repair. More specifically, the present invention relates to repair of an atrioventricular valve and associated chordeae tendineae of a patient.

BACKGROUND

Ischemic heart disease causes mitral regurgitation by the combination of ischemic dysfunction of the papillary muscles, and the dilatation of the left ventricle that is present in ischemic heart disease, with the subsequent displacement of the papillary muscles and the dilatation of the mitral valve annulus.

Dilation of the annulus of the mitral valve prevents the valve leaflets from fully coapting when the valve is closed. Mitral regurgitation of blood from the left ventricle into the left atrium results in increased total stroke volume and decreased cardiac output, and ultimate weakening of the left ventricle secondary to a volume overload and a pressure overload of the left atrium.

Chronic or acute left ventricular dilatation can lead to papillary muscle displacement with increased leaflet tethering due to tension on chordae tendineae, as well as annular dilatation.

SUMMARY OF THE INVENTION

In some applications of the present invention, apparatus is provided comprising an implant comprising one or more primary adjustable repair chords and an adjustment mechanism that is configured to adjust a tension of the one or more adjustable repair chords and that is slidable along a guide wire toward an implantation site. Additionally, the apparatus comprises a first tissue-engaging element (e.g., a tissue anchor) that comprises one or more docking stations. Further additionally, in accordance with some applications of the present invention, a method is provided for implanting such apparatus. A respective guide wire is reversibly coupled to each one of the docking stations. The adjustment mechanism is slidable along the guide wire toward one of the one or more docking stations, and is coupled to the tissue-engaging element via the docking station. Thus, the docking station is a coupling element that provides coupling between two other elements (in this case, between adjustment mechanism and the tissue-engaging element.)

The repair chord comprises a flexible, longitudinal member (e.g., sutures or wires). The repair chord is coupled at a distal portion thereof to the adjustment mechanism. In some applications, the repair chord functions as artificial chordae tendineae. In other applications, the repair chord is used to adjust a distance between two portions of the ventricular wall. For some applications, the repair chord is coupled at a proximal portion thereof to a second tissue-engaging element (e.g., a tissue anchor which penetrates or clips a portion of tissue).

For other applications, the repair chord comprises a cord that is disposed within at least a portion of an annuloplasty ring structure (e.g., a full annuloplasty ring or a partial annuloplasty ring). For such applications, the annuloplasty ring structure comprises the adjustment mechanism that is coupled to the repair cord. The annuloplasty ring structure is slidable along the guide wire toward one of the one or more docking stations, and is coupled to the tissue-engaging element via the docking station. It is to be noted that the annuloplasty ring structure may be provided independently of the adjustment mechanism and the repair chord. For such applications, the annuloplasty ring structure is slidable along the guide wire toward one of the one or more docking stations, and is coupled to the tissue-engaging element via the docking station.

For yet other applications, a prosthetic heart valve and/or a support for the prosthetic heart valve is slidable along the guide wire toward one of the one or more docking stations, and is coupled to the tissue-engaging element via the docking station.

Thus, the tissue-engaging element and the docking station are used to facilitate implantation of an implant such as cardiac valve implants, namely annuloplasty ring structures, prosthetic valves, and/or apparatus for receiving a prosthetic valve (e.g., a docking station or a support for receiving the prosthetic valve).

Typically, during a transcatheter procedure, the first tissue-engaging element is coupled to a first portion of tissue at a first implantation site in a heart of a patient. The adjustment mechanism is then slid along the guide wire and toward the first tissue-engaging element at the first implantation site. The proximal portion of the repair chord is then coupled via the second tissue-engaging element to a second portion of tissue at a second implantation site. Following the coupling of the second tissue-engaging element to the second implantation site, the adjustment mechanism is further slid distally toward the first tissue-engaging element and is then coupled to the first tissue-engaging element via the one or more docking stations on the first tissue-engaging element. Following the coupling of the adjustment mechanism to the second tissue-engaging element, a length and tension of the repair chord is then adjusted in order to adjust a distance between the first and second implantation sites. For applications in which the repair chord functions as an artificial chordea tendinea, the adjustment of the length and tension of the repair chord draws the leaflets together, and/or pulls the leaflet down toward the first implantation site to repair the valve.

In some applications of the present invention, the adjustment mechanism comprises a spool assembly which adjusts a degree of tension of the repair chord. The spool assembly comprises a housing, which houses a spool to which a distal portion of the repair chord is coupled.

For applications in which the repair chord is coupled to two respective portions of the ventricular wall, the two portions are drawn together, thereby restoring the dimensions of the heart wall to physiological dimensions, and drawing the leaflets toward one another.

In some applications of the present invention, the adjustment mechanism comprises a reversible locking mechanism which facilitates bidirectional rotation of the spool in order to effect both tensioning and relaxing of the repair chord. That is, the spool is wound in one direction in order to tighten the repair chord, and in an opposite direction in order to slacken the repair chord. Thus, the spool adjustment mechanism facilitates bidirectional adjustment of the repair chord.

In some applications of the present invention, the adjustable repair chord is implanted during an open-heart or minimally-invasive procedure. In these applications, the delivery tool comprises a handle and a multilumen shaft that is coupled at a distal end thereof to the adjustment mechanism. The delivery tool functions to advance the adjustment mechanism to the first portion of tissue, implant the adjustment mechanism at the first portion of tissue, and effect adjustment of the repair chord by effecting rotation of the spool. For applications in which the repair chord functions as an artificial chordea tendinea, prior to implantation of the adjustment mechanism, the distal portion of the delivery tool and the adjustment mechanism coupled thereto are advanced between the leaflets of the atrioventricular valve and into the ventricle toward the first portion of tissue. The incision made in the heart is then closed around the delivery tool and the heart resumes its normal function during the adjustment of the length of the artificial chordea tendinea.

In some applications of the present invention, apparatus and method described herein may be used for providing artificial chordae tendineae in a left ventricle of the heart and effecting adjustment thereof. In some applications, apparatus and method described herein may be used for providing artificial chordae tendineae in a right ventricle of the heart and effecting adjustment thereof. In some applications, apparatus and method described herein may be used for providing a system to adjust a length between two portions of the heart wall. For other applications apparatus and method described herein may be used for providing a docking station for an annuloplasty ring or for a prosthetic valve.

There is therefore provided, in accordance with an application of the present invention, apparatus, including:

-   -   a guide member;     -   a tissue-adjustment mechanism having:         -   an upper surface and a lower surface,         -   at least one first opening at the upper surface,         -   at least one second opening at the lower surface, and         -   a channel extending between the first and second openings,             the channel facilitating advancement of the             tissue-adjustment mechanism along the guide member; and     -   at least one repair chord coupled at a first portion thereof to         the tissue-adjustment mechanism and having at least a first end         that is configured to be coupled to a portion of tissue of a         patient, the repair chord being configured to adjust a distance         between the portion of tissue and the tissue-adjustment         mechanism, in response to adjustment of the repair chord by the         tissue-adjustment mechanism.

There is further provided, in accordance with an application of the present invention, a method, including:

-   -   coupling a guide member to a portion of tissue of a patient; and     -   advancing a tissue-adjustment mechanism toward the portion of         tissue by:         -   threading a portion of the guide member through at least one             channel extending between a first opening in an upper             surface of the tissue-adjustment mechanism and a second             opening in a lower surface of the tissue-adjustment             mechanism; and         -   advancing the tissue-adjustment mechanism along the guide             member and toward the portion of tissue.

There is further provided, in accordance with an application of the present invention, apparatus for use with tissue of a heart of a subject, the apparatus including:

at least one docking assembly, having:

a distal portion including a tissue anchor that is configured to engage a portion of the tissue,

a proximal portion, fixedly coupled to the distal portion, and including at least one docking station that includes a first coupling;

-   -   at least one guide member, reversibly coupled to the at least         one docking station; and     -   an annuloplasty ring selected from the group consisting of: a         partial annuloplasty ring and a full annuloplasty ring, the         selected annuloplasty ring being:

shaped to define a second coupling, and

slidable along the guide member toward the docking station, and

configured to be locked to the docking station by the second coupling being lockable to the first coupling.

In an application, the second coupling is lockable to the first coupling by being pushed against the first coupling.

In an application, the annuloplasty ring is configured to be locked to the docking station suturelessly.

In an application, the docking assembly is percutaneously deliverable to the heart of the subject, and the annuloplasty ring is percutaneously lockable to the docking station.

In an application:

-   -   the at least one docking assembly includes a plurality of         docking assemblies,     -   the at least one guide member includes a respective plurality of         guide members, each of the guide members being reversibly         coupled to a respective docking station of a respective docking         assembly,     -   the selected annuloplasty ring is shaped to define a respective         plurality of second couplings, and is slidable along the         plurality of guide members toward the plurality of docking         assemblies, and     -   the each of the second couplings is lockable to a respective         first coupling of a respective docking assembly.

In an application, the selected annuloplasty ring includes an adjustable annuloplasty ring, including a rotatable structure that is:

-   -   bidirectionally rotatable to adjust the selected annuloplasty         ring,     -   shaped to define a channel between an upper surface thereof and         a lower surface thereof, the guide member being disposable in         the channel, and     -   shaped to define the second coupling, and     -   the selected annuloplasty ring is slidable along the guide         member by the rotatable structure being slidable along the guide         member.

In an application:

-   -   the selected annuloplasty ring includes:         -   a sleeve, having a longitudinal length from a first end             thereof to a second end thereof, and defining lumen             therebetween,         -   a flexible longitudinal member, at least part of which is             disposed in at least part of the lumen, and         -   the rotatable structure, and     -   the rotatable structure is:     -   coupled to a first end portion of the flexible longitudinal         member, and     -   bidirectionally rotatable to adjust the longitudinal length of         the sleeve by adjusting a degree of tension of the flexible         longitudinal member.

In an application, the apparatus further includes a rotatable structure locking mechanism displaceable with respect to the rotatable structure, so as to release the rotatable structure during rotation of the rotatable structure, and lock in place the rotatable structure following rotation of the rotatable structure.

In an application, the apparatus further includes a release rod:

-   -   shaped to define a lumen therethrough, the guide member being         disposable within the lumen of the release rod, and     -   configured to unlock the rotatable structure locking mechanism         by being slid over the guide member.

There is further provided, in accordance with an application of the present invention, apparatus, including:

-   -   a docking assembly:         -   having a distal portion including a tissue anchor that is             configured to engage cardiac tissue of a subject,         -   having a proximal portion including at least one docking             station that includes a first coupling;     -   a guide member reversibly coupled to the at least one docking         station; and     -   an adjustable annuloplasty ring selected from the group         consisting of: a partial annuloplasty ring and a full         annuloplasty ring, the selected annuloplasty ring:     -   a. including:     -   a sleeve, having a longitudinal length from a first end thereof         to a second end thereof, and defining lumen therebetween,         -   a flexible longitudinal member, at least part of which is             disposed in at least part of the lumen, and         -   a rotatable structure:             -   coupled to a first end portion of the flexible                 longitudinal member,             -   bidirectionally rotatable to adjust the longitudinal                 length of the sleeve by adjusting a degree of tension of                 the flexible longitudinal member,             -   shaped to define (1) a channel between an upper surface                 thereof and a lower surface thereof, the guide member                 being disposable in the channel, and (2) a second                 coupling, and     -   b. being slidable along the guide member toward the docking         assembly, and configured to lock the selected annuloplasty ring         to the docking assembly by the second coupling being lockable to         the first coupling.

In an application, the apparatus further includes a rotatable structure locking mechanism displaceable with respect to the rotatable structure, so as to release the rotatable structure during rotation of the rotatable structure, and lock in place the rotatable structure following rotation of the rotatable structure.

In an application, the apparatus further includes a release rod:

-   -   shaped to define a lumen therethrough, the guide member being         disposable within the lumen of the release rod, and     -   configured to unlock the rotatable structure locking mechanism         by being slid over the guide member.

There is further provided, in accordance with an application of the present invention, a method for use with tissue of a heart of a subject, the method including:

-   -   advancing a docking station assembly to the tissue, the docking         station assembly including (1) a distal portion including a         tissue anchor that is configured to engage a portion of the         tissue, and (2) a proximal portion, fixedly coupled to the         distal portion, and including at least one docking station that         includes a first coupling;     -   advancing, along a guide member that is reversibly coupled to         the docking station, an annuloplasty ring selected from the         group consisting of: a partial annuloplasty ring and a full         annuloplasty ring, the selected annuloplasty ring being shaped         to define a second coupling; and     -   locking the selected annuloplasty ring to the docking station by         locking the second coupling to the first coupling.

There is further provided, in accordance with an application of the present invention, apparatus for use with at least one implant, including:

-   -   a tissue-engaging element having (a) a distal portion configured         to engage at least a first portion of tissue of a patient,         and (b) a proximal portion;     -   at least one docking station coupled to the proximal portion of         the tissue-engaging element, the at least one docking station:         -   being configured to receive and be coupled to the at least             one implant, and         -   including a locking mechanism configured to lock the implant             to the docking station; and     -   at least one guide member reversibly coupled to the at least one         docking station, the at least one guide member being configured         for facilitating slidable advancement of the at least one         implant toward the docking station.

In an application, the at least one docking station includes two or more docking stations, and the at least one guide member includes two or more guide members, each guide member being reversibly coupled to a respective docking station.

In an application, the implant includes at least one implant selected from the group consisting of: a prosthetic cardiac valve and a support for receiving a prosthetic cardiac valve, and the at least one docking station is configured to receive and be coupled to the selected implant.

In an application, the implant includes a tissue-adjustment device selected from the group consisting of: a partial annuloplasty ring and a full annuloplasty ring, and the at least one docking station is configured to receive and be coupled to the selected tissue-adjustment device.

In an application, the apparatus further includes the implant.

In an application, the implant has:

an upper surface and a lower surface,

at least one first opening at the upper surface,

at least one second opening at the lower surface, and

a channel extending between the first and second openings, the channel facilitating advancement of the implant along the guide member.

In an application, the implant includes a first coupling, and the locking mechanism includes a second coupling configured to be coupled to the first coupling.

In an application, the second coupling includes at least one depressed portion, and the first coupling includes at least one moveable baffle which is configured to engage the at least one depressed portion of the second coupling.

In an application, the apparatus further includes at least one flexible longitudinal member coupled at a first portion thereof to the implant, a second portion of the flexible longitudinal member is configured to be coupled to a second portion of tissue of the patient, and the implant is configured to adjust a length of the longitudinal member between the first and second portions of tissue.

In an application:

-   -   the first portion of tissue includes a first portion of cardiac         tissue at a first intraventricular site,     -   the second portion of tissue includes at least one leaflet of an         atrioventricular valve of the patient, and     -   the flexible longitudinal member includes at least one         artificial chordea tendinea.

In an application:

-   -   the implant includes a rotatable structure,     -   the at least one flexible longitudinal member is coupled at the         first portion to the rotatable structure, and     -   the rotatable structure is bidirectionally rotatable to adjust         the degree of tension of the at least one flexible longitudinal         member.

In an application, the rotatable structure is configured such that:

-   -   rotation of the rotatable structure in a first rotational         direction applies tension to the flexible longitudinal member,         and     -   rotation of the rotatable structure in a second rotational         direction that is opposite the first rotational direction         slackens the flexible longitudinal member.

In an application, the apparatus further includes a rotatable structure locking mechanism displaceable with respect to the rotatable structure, so as to:

-   -   release the rotatable structure during rotation of the rotatable         structure, and     -   lock in place the rotatable structure following rotation of the         rotatable structure.

In an application, the rotatable structure includes a spool, and the at least one flexible longitudinal member is configured to be wound around the spool during the rotation of the spool in a first rotational direction.

In an application:

-   -   the implant includes a rotatable structure, coupled to a         flexible longitudinal member,     -   the rotatable structure is bidirectionally rotatable to adjust a         degree of tension of the flexible longitudinal member, and     -   the at least one docking station is configured to receive and be         coupled to the rotatable structure.

There is further provided, in accordance with an application of the present invention, apparatus for use with at least one implant, including:

-   -   a tissue-engaging element having (a) a distal portion configured         to engage at least a first portion of tissue of a patient,         and (b) a proximal portion;     -   at least one docking station coupled to the proximal portion of         the tissue-engaging element, the at least one docking station:         -   being configured to receive and be coupled to the at least             one implant, and         -   including a locking mechanism configured to lock the implant             to the tissue-engaging element; and     -   at least one guide member reversibly coupled to the at least one         docking station, the at least one guide member being configured         for facilitating slidable advancement of the at least one         implant toward the tissue-engaging element.

In an application, the guide member is looped around a portion of the docking station.

In an application, the at least one docking station includes two or more docking stations, and the at least one guide member includes two or more guide members, each guide member being reversibly coupled to a respective docking station.

In an application, the implant includes a prosthetic cardiac valve.

In an application, the implant includes a support for receiving a prosthetic cardiac valve.

In an application, the implant includes a tissue-adjustment device.

In an application, the tissue-adjustment device includes an annuloplasty ring structure selected from the group consisting of: a partial annuloplasty ring and a full annuloplasty ring.

In an application, the apparatus further includes the implant, and the implant has:

an upper surface and a lower surface,

at least one first opening at the upper surface,

at least one second opening at the lower surface, and

a channel extending between the first and second opening, the channel facilitating advancement of the implant along the guide member.

In an application, the implant includes a prosthetic cardiac valve.

In an application, the implant includes a support for receiving a prosthetic cardiac valve.

In an application, the implant includes a tissue-adjustment device.

In an application, the tissue-adjustment device includes an annuloplasty ring structure selected from the group consisting of: a partial annuloplasty ring and a full annuloplasty ring.

In an application, the implant includes a first coupling, and the locking mechanism includes a second coupling configured to be coupled to the first coupling.

In an application, the second coupling includes at least one depressed portion, and the first coupling includes at least one moveable baffle which is configured to engage the at least one depressed portion of the second coupling.

In an application, the apparatus further includes at least one flexible longitudinal member coupled at a first portion thereof to the implant, a second portion of the flexible longitudinal member is configured to be coupled to a second portion of tissue of the patient, and the implant is configured to adjust a length of the longitudinal member between the first and second portions of tissue.

In an application:

-   -   the first portion of tissue includes a first portion of cardiac         tissue at a first intraventricular site,     -   the second portion of tissue includes at least one leaflet of an         atrioventricular valve of the patient, and     -   the flexible longitudinal member includes at least one         artificial chordea tendinea.

In an application:

-   -   the implant includes a rotatable structure,     -   the at least one flexible longitudinal member is coupled at the         first portion to the rotatable structure, and     -   the rotatable structure is bidirectionally rotatable to adjust         the degree of tension of the at least one flexible longitudinal         member.

In an application, during rotation of the rotatable structure in a first rotational direction, successive portions of the flexible longitudinal member advance in a first advancement direction with respect to the rotatable structure and contact the rotatable structure, to pull the second portion of the flexible member toward the rotatable structure, and to draw the first and second portions of tissue toward each other.

In an application, the apparatus further includes a rotatable structure locking mechanism displaceable with respect to the rotatable structure, so as to:

-   -   release the rotatable structure during rotation of the rotatable         structure, and     -   lock in place the rotatable structure following rotation of the         rotatable structure.

In an application, the rotatable structure includes a spool, and the at least one flexible longitudinal member is configured to be wound around the spool during the rotation of the spool in a first rotational direction.

In an application, the first portion of the at least one flexible longitudinal member is looped through a portion of the spool.

In an application, the first portion of the at least one flexible longitudinal member is wound around a portion of the spool, and the first portion of the at least one flexible longitudinal member is configured to be unwound from around the portion of the spool following the coupling of the second portion of the flexible longitudinal member to the second portion of tissue of the patient.

There is further provided, in accordance with an application of the present invention, apparatus, including:

-   -   a tissue-engaging element having a distal portion configured to         engage at least a first portion of tissue of a patient, and         having a proximal portion;     -   at least one docking station coupled to the proximal portion of         the tissue-engaging element, the at least one docking station         being configured to be coupled to the at least one         tissue-adjustment device;     -   an implant including:         -   a rotatable structure; and         -   at least one flexible longitudinal member having a first             portion thereof that is in contact with the rotatable             structure, and a second portion thereof that is configured             to be coupled to a second portion of tissue of the patient,         -   and during rotation of the rotatable structure in a first             rotational direction, successive portions of the flexible             longitudinal member advance in a first advancement direction             with respect to the rotatable structure and contact the             rotatable structure, and, pull the second portion of the             flexible longitudinal member toward the implant, and             responsively, to draw the first and second portions of             tissue toward each other; and     -   at least one guide member reversibly coupled to the at least one         docking station, the at least one guide member being configured         for facilitating slidable advancement of the at least one         implant toward the tissue-engaging element.

In an application, the guide member is looped around a portion of the docking station.

In an application, the at least one docking station includes two or more docking stations, and the at least one guide member includes two or more guide members, each guide member being reversibly coupled to a respective docking station.

In an application, the implant includes a support for receiving a prosthetic cardiac valve.

In an application, the implant includes a tissue-adjustment device.

In an application, the tissue-adjustment device includes an annuloplasty ring structure selected from the group consisting of: a partial annuloplasty ring and a full annuloplasty ring.

In an application, the implant has:

an upper surface and a lower surface,

at least one first opening at the upper surface,

at least one second opening at the lower surface, and

a channel extending between the first and second opening, the channel facilitating advancement of the implant along the guide member.

In an application, the implant includes a first coupling, and the docking station includes a second coupling configured to be coupled to the first coupling.

In an application, the second coupling includes at least one depressed portion, and the first coupling includes at least one moveable baffle which is configured to engage the at least one depressed portion of the second coupling.

In an application, the second coupling includes a locking mechanism configured to lock the implant to the tissue-engaging element.

In an application:

-   -   the first portion of tissue includes a first portion of cardiac         tissue at a first intraventricular site,     -   the second portion of tissue includes at least one leaflet of an         atrioventricular valve of the patient, and     -   the flexible longitudinal member includes at least one         artificial chordea tendinea.

In an application, the rotatable structure is rotatable in a first rotational direction to apply tension to the flexible longitudinal member, and in a second rotational direction that is opposite the first rotational direction to slacken the flexible longitudinal member.

In an application, during rotation of the rotatable structure in a first rotational direction thereof, successive portions of the flexible longitudinal member advance in a first advancement direction with respect to the rotatable structure and contact the rotatable structure, responsively, to pull the second portion of the flexible longitudinal member toward the rotatable structure.

In an application, the apparatus further includes a rotatable structure locking mechanism, displaceable with respect to the rotatable structure so as to:

-   -   release the rotatable structure during rotation of the rotatable         structure, and     -   lock in place the rotatable structure following rotation of the         rotatable structure.

In an application, the rotatable structure includes a spool, and the at least one flexible longitudinal member is configured to be wound around the spool during the rotation of the spool in the first rotational direction.

In an application, the first portion of the flexible longitudinal member is looped through a portion of the spool.

In an application, the first portion of the flexible longitudinal member is wound around a portion of the spool, and the first portion of the flexible longitudinal member is configured to be unwound from around the portion of the spool following the coupling of the second portion of the flexible longitudinal member to the second portion of tissue of the patient.

There is further provided, in accordance with an application of the present invention, apparatus, including:

-   -   a guide member;     -   a tissue-adjustment mechanism having:         -   an upper surface and a lower surface,         -   at least one first opening at the upper surface,         -   at least one second opening at the lower surface, and         -   a channel extending between the first and second openings,             the channel facilitating advancement of the             tissue-adjustment mechanism along the guide member; and     -   at least one repair chord coupled at a first portion thereof to         the tissue-adjustment mechanism and having at least a first end         that is configured to be coupled to a portion of tissue of a         patient, the repair chord being configured to adjust a distance         between the portion of tissue and the tissue-adjustment         mechanism, in response to adjustment of the repair chord by the         tissue-adjustment mechanism.

The present invention will be more fully understood from the following detailed description of embodiments thereof, taken together with the drawings, in which:

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1-2 are schematic illustrations of apparatus comprising a tissue-engaging element comprising a docking station coupled to a guide wire, in accordance with some applications of the present invention;

FIG. 3 is a schematic illustration of advancement of an adjustment mechanism along the guide wire toward the docking station of FIGS. 1 and 2, in accordance with some applications of the present invention;

FIGS. 4-5 are schematic illustrations of engaging a leaflet with a leaflet engaging element, in accordance with some applications of the present invention;

FIG. 6 is a schematic illustration of coupling of the adjustment mechanism of FIG. 3 to the docking station, in accordance with some applications of the present invention;

FIGS. 7-9 are schematic illustrations of adjusting by the adjustment mechanism a length of a repair chord coupled to the adjustment mechanism, in accordance with some applications of the present invention;

FIG. 10 is a schematic illustration of the adjustment mechanism and the repair chord, in accordance with some other applications of the present invention;

FIGS. 11-15 are schematic illustrations of a plurality of docking stations and a plurality of adjustment mechanisms, in accordance with some applications of the present invention;

FIG. 16 is a schematic illustration of wall-to-wall adjustment using the docking station, adjustment mechanism, and repair chord, in accordance with some applications of the present invention;

FIG. 17 is a schematic illustration of wall-to-wall adjustment and leaflet adjustment using the plurality of docking stations, the plurality of adjustment mechanisms, and the plurality of repair chords, in accordance with some applications of the present invention;

FIG. 18 is a schematic illustration of wall-to-wall adjustment using the docking station, adjustment mechanism, and repair chord, in accordance with some other applications of the present invention;

FIGS. 19-20 are schematic illustrations of adjustment of a valve of a patient from a middle portion of the valve, in accordance with some applications of the present invention;

FIG. 21 is a schematic illustration of the tissue-engaging element and the docking station of FIGS. 1 and 2 being used to facilitate implantation of an implant at a cardiac valve, in accordance with some applications of the present invention; and

FIG. 22 is a schematic illustration of the tissue-engaging element and the docking station of FIGS. 1 and 2 being used to facilitate implantation of an annuloplasty ring at a cardiac valve, in accordance with some applications of the invention.

DETAILED DESCRIPTION OF EMBODIMENTS

Reference is now made to FIGS. 1-2, which are schematic illustrations of a system 20 comprising a docking assembly 150 for implantation at a first implantation site 5 of a patient, in accordance with some applications of the present invention. As shown in FIG. 2, docking assembly 150 comprises a tissue-engaging element having (1) a distal portion comprising a tissue anchor 50 (e.g., a helical tissue anchor as shown by way of illustration and not limitation), and (2) a proximal portion comprising a docking platform 54, and at least one docking station 56. Thus, docking assembly 150 comprises (a) the distal portion which engages the tissue of the patient (i.e., the tissue-engaging element), and (b) the proximal portion which is coupled to docking station 56. It is to be noted that the distal portion and the proximal portion are fixedly coupled to each other (e g , immovable with respect to each other), and thereby docking station 56 and tissue anchor 50 are fixedly coupled to each other (e g , immovable with respect to each other). Docking assembly 150 is thereby an integrated unit that comprises the docking station and tissue anchor. At least one guide member, (e.g., a guide wire 40, shown in FIG. 2) is reversibly coupled to docking assembly 150 (e.g., by being looped around, or otherwise coupled to, a portion of assembly 150) so as to define first and second portions 40 a and 40 a′ that extend away from assembly 150.

Tissue anchor 50 is typically implanted within cardiac tissue in a manner in which a distal portion of anchor 50 does not extend beyond an epicardium of heart 2 of the patient. Thus, anchor 50 is implanted at an intracardiac site such that the implant, (e.g., the adjustment mechanism or an implant comprising the adjustment mechanism) that is eventually coupled thereto (as described hereinbelow) is implanted at the intracardiac site such that no portions of the adjustment mechanism extend beyond the epicardium of the heart.

Docking assembly 150 and guide wire 40 are advanced toward implantation site typically during a transcatheter procedure, as shown. However, it is to be noted that the scope of the present invention includes the advancement of assembly 150 and guide wire 40 during a minimally-invasive or open-heart procedure. The procedure is typically performed with the aid of imaging, such as fluoroscopy, transesophageal echo, and/or echocardiography.

The transcatheter procedure typically begins with the advancing of a semi-rigid guide wire into a right atrium of the patient. The semi-rigid guide wire provides a guide for the subsequent advancement of a sheath 28 therealong and into the right atrium. Once sheath 28 has entered the right atrium, the semi-rigid guide wire is retracted from the patient's body. Sheath 28 typically comprises a 13-20 F sheath, although the size may be selected as appropriate for a given patient. Sheath 28 is advanced through vasculature into the right atrium using a suitable point of origin typically determined for a given patient. For example:

-   -   sheath 28 may be introduced into the femoral vein of the         patient, through an inferior vena cava, into the right atrium,         and into the left atrium transseptally, typically through the         fossa ovalis;     -   sheath 28 may be introduced into the basilic vein, through the         subclavian vein to the superior vena cava, into the right         atrium, and into the left atrium transseptally, typically         through the fossa ovalis; or     -   sheath 28 may be introduced into the external jugular vein,         through the subclavian vein to the superior vena cava, into the         right atrium, and into the left atrium transseptally, typically         through the fossa ovalis.

In some applications of the present invention, sheath 28 is advanced through the inferior vena cava of the patient (as shown) and into the right atrium using a suitable point of origin typically determined for a given patient.

Sheath 28 is advanced distally until the sheath reaches the interatrial septum. For some applications, a resilient needle and a dilator (not shown) are advanced through sheath 28 and into the heart. In order to advance sheath 28 transseptally into the left atrium, the dilator is advanced to the septum, and the needle is pushed from within the dilator and is allowed to puncture the septum to create an opening that facilitates passage of the dilator and subsequently sheath 28 therethrough and into the left atrium. The dilator is passed through the hole in the septum created by the needle. Typically, the dilator is shaped to define a hollow shaft for passage along the needle, and the hollow shaft is shaped to define a tapered distal end. This tapered distal end is first advanced through the hole created by the needle. The hole is enlarged when the gradually increasing diameter of the distal end of the dilator is pushed through the hole in the septum.

The advancement of sheath 28 through the septum and into the left atrium is followed by the extraction of the dilator and the needle from within sheath 28. Subsequently, a docking-assembly delivery tool 30 is advanced through sheath 28. Tool 30 is typically advanced within a lumen of an advancement sheath 22 having a distal end 24. Advancement sheath 22 is advanced within sheath 28. Delivery tool 30 is coupled at a distal end thereof to a manipulator 32 which is reversibly coupled to docking station 56 and docking platform 54 of docking assembly 150. Manipulator 32 has (1) lateral arms which cup platform 54, and (2) a docking-station-coupler 34, as shown in FIG. 1. Coupler 34 is biased to move radially-inward, as shown in FIG. 1. Docking station 56 is ribbed, such that coupler 34, when moved radially inward, engages at least one rib of docking station 56, thereby coupling assembly 150 to delivery tool 30.

Delivery tool 30 and manipulator 32 are shaped so as to define a lumen for passage therethrough of guide wire 40.

Docking assembly 150 is implanted in implantation site 5 by rotating tool 30 in order to rotate anchor 50 and corkscrew anchor 50 into tissue of site 5. Site 5 typically comprises a portion of tissue at an intraventricular site in heart 2 of the patient. As shown, site 5 includes a papillary muscle 4, by way of illustration and not limitation. It is to be noted that site 5 includes any portion of cardiac tissue, e.g., a portion of a free wall of the ventricle, a portion of the septum facing the ventricle, a portion of tissue at a base of the papillary muscle, or a portion of the wall at the apex of the ventricle. (For the purposes of the claims, “a portion of tissue of a ventricle” includes any portion of cardiac tissue, e.g., a portion of a free wall of the ventricle, a portion of the septum facing the ventricle, a portion of tissue at a base of the papillary muscle, or a portion of the wall at the apex of the ventricle.)

Following the implantation of assembly 150 at site 5, tool 30 is disengaged from assembly 150 when the physician pulls on tool 30. This pulling pulls on manipulator 32 such that coupler 34 is actively moved radially outward against the ribs of docking station 56, and is thereby decoupled from station 56. At the time of pulling, tissue at implantation site 5 pulls on assembly 150 (in the direction opposite the direction of pulling by the physician) so as to help disengage tool 30 from assembly 150.

As shown in FIG. 2, following the decoupling of tool 30 from assembly 150, tool 30 is pulled proximally along guide wire 40 and is extracted from the body of the patient together with advancement sheath 22, leaving behind assembly 150 and guide wire 40.

FIG. 3 shows advancement of an implant (e.g., a spool assembly 36 comprising an adjustment mechanism 43) along guide wire 40 by an adjustment-mechanism delivery tool 64, in accordance with some applications of the present invention. Tool 64 is surrounded by and slidable within an advancement sheath 60 having a distal end 62.

Spool assembly 36 is surrounded by a braided fabric mesh, e.g., a polyester mesh, which promotes fibrosis around assembly 36 and facilitates coupling of assembly 36 to tissue of heart 2. Assembly 36 houses a rotatable structure (e.g., a spool as shown hereinbelow) that is surrounded by a housing 49. Housing 49 is coupled to a distal cap 44 which facilitates coupling of assembly 36 to docking station 56 of docking assembly 150. As shown, cap 44 is shaped so as to define a plurality of baffles 47 that are disposed angularly with respect to a distal end of cap 44. Baffles 47 are coupled to the distal end of cap 44 along respective coupling joints which facilitate movement of each baffle 47. During the coupling of spool assembly 36 to docking station 56, the ribbed portion of docking station 56 pushes inwardly baffles 47 of cap 44, as is described hereinbelow. Baffles 47 then expand and engage an area of docking station 56 between the ribs of the ribbed portion so as to dock and lock assembly 36 to docking station 56.

Additionally, cap 44 is shaped so as to define a central opening therethrough which facilitates passage therethrough of guide wire 40. Additionally, spool assembly 36 and the components thereof are shaped so as to define a central opening (i.e., an opening having the same axis as guide wire 40). That is, spool 46 has a central opening, and housing 49 has a central opening which facilitates passage of spool 46 and housing 49 along guide wire 40.

As shown, adjustment mechanism 43 is coupled to a distal portion of a repair chord 74 (e.g., repair chord 74 is looped through or otherwise coupled to a portion of adjustment mechanism 43). Chord 74 comprises a flexible longitudinal member. For some applications, and as is described hereinbelow, chord 74 functions as an artificial chordea tendinea. A proximal portion of chord 74 is coupled to a leaflet-engaging element 72 (e.g., a clip, as shown). Leaflet-engaging element 72 is disposed within a holder 70 that is coupled to delivery tool 64. Chord 74 a superelastic, biocompatible material (e.g., nitinol, ePTFE, PTFE, polyester, stainless steel, or cobalt chrome). Typically, chord 74 comprises an artificial chordea tendinea.

FIGS. 4-5 are schematic illustrations of the engaging of leaflet-engaging element 72 to at least one leaflet 14 of a mitral valve of the patient, in accordance with some applications of the present invention. As shown in FIG. 4, the clip is opened from a remote location outside the body of the patient.

For some applications, the clip typically is shaped so as to define at least one coupling protrusion 73. The clip has a tendency to close, and is initially held open by a cord (not shown) that is coupled to a surface of the clip, extends through delivery tool 64, and is held taught outside of the heart. Once the clip has been advanced to the desired location on the leaflet, the cord is relaxed, allowing the clip to close. The cord is removed, typically by releasing one end thereof and pulling the other end. The positioning of holder 70 between the leaflets (FIG. 5) helps ensure that the clip engages exactly one of the leaflets. It is noted that in FIG. 5 the clip is shown engaging only a single leaflet (leaflet 14). The clip typically engages the leaflet by clamping the leaflet such that the clip engages atrial and ventricular surfaces of the leaflet. The clip may puncture the leaflet, or may merely press firmly against the leaflet.

It is to be noted that the scope of the present invention includes the clipping together of both leaflets 12 and 14. For applications in which system 20 is used to repair a tricuspid valve of the patient, the clip may clip any one, two, or all three leaflets together.

Holder 70 is shaped to define a groove which houses the clip during the advancement of tool 64 toward the ventricle. The groove functions as a track to facilitate slidable detachment of the clip from holder 70 following the engaging of the clip to leaflet 14.

Alternatively, the clip has a tendency to open. In order to close the clip, a cord is provided. A distal-most portion of the cord is looped around the clip. Once the clip has been advanced to the desired location on the leaflet, as shown in FIG. 5, the surgeon pulls on both ends of the cord, thereby causing the clip to become locked closed. The cord is removed, typically by releasing one end thereof and pulling the other end.

It is to be noted that the scope of the present invention includes any leaflet-engaging element known in the art.

As shown in FIG. 5, portions 74 a and 74 b extend from leaflet-engaging element 72 toward adjustment mechanism 43. Portions 74 a and 74 b define portions of a single chord 74 that is looped through a portion of mechanism 43. Alternatively, portions 74 a and 74 b represent two distinct chords which are coupled at their distal ends to adjustment mechanism 43 and at their proximal ends to leaflet-engaging element 72.

As shown, leaflet-engaging element 72 engages leaflet 14 prior to coupling spool assembly 36 to docking station 56.

FIG. 6 shows spool assembly 36 being coupled to docking station 56, in accordance with some applications of the present invention. Following the coupling of leaflet-engaging element 72 to leaflet 14, spool assembly 36 is pushed distally toward docking station 56. Spool assembly 36 is coupled to an advancement shaft 80 which pushes assembly 36. Shaft 80 slides within a lumen of delivery tool 64 and within a lumen of holder 70 so as to advance spool assembly 36, while leaflet-engaging element 72 remains engaged with leaflet 14. Advancement shaft 80 functions to advance distally spool assembly 36 and functions to facilitate engagement between spool assembly 36 and docking station 56.

As described hereinabove, docking station 56 has one or more locking mechanisms (e.g., one or more ribs 57, shown in the enlarged cross-sectional image of FIG. 6) which project laterally such that rib 57 defines a shelf and a depressed area underneath the shelf (i.e., the cross-sectional diameter at rib 57 is larger than the cross-sectional diameter at the area underneath the shelf). As described hereinabove, cap 44 of assembly 36 is shaped so as to define a plurality of baffles 47. As cap 44 engages docking station 56, baffles 47 are pushed inward and upward angularly as each baffle slides against rib 57. After each baffle 47 passes the shelf of rib 57, the baffle engages the depressed area underneath the shelf of rib 57, as shown in the enlarged cross-sectional image of FIG. 6. The shelf of rib 57 prevents upward movement of baffles 47 and thereby locks in place baffles 47 and cap 44 with respect to docking station 56. Rib 57, therefore, comprises a locking mechanism so as to lock implant 42 (e.g., adjustment mechanism 43) to tissue anchor 50.

Following the coupling of assembly 36 to docking station 56, spool 46 is rotated in a first rotational direction in order to advance with respect to spool 46 and contact with spool 46 successive portions of chord 74. For example, when the successive portions of chord 74 are advanced with respect to spool 46, the successive portions of chord 74 are looped around spool 46. The rotating of spool 46 in the first rotational direction pulls tight and adjusts a length of chord 74 between leaflet 14 and spool 46, in order to adjust a distance between leaflet 14 and implantation site 5 and to facilitate coaptation between leaflets 12 and 14, as is described hereinbelow.

Housing 49 is shaped so as to provide openings 41 a and 41 b for passage therethrough of portions 74 a and 74 b, respectively, of chord 74 into housing 49. For some applications of the present invention, portions 74 a and 74 b define portions of a single chord 74 that is looped through spool 46. For other applications, portions 74 a and 74 b define discrete chords which are each coupled at respective distal ends thereof to spool 46.

The enlarged, cross-sectional image of FIG. 6 shows spool 46 within housing 49. Spool 46 defines an upper surface 150, a lower surface 152, and a cylindrical body portion disposed vertically between surfaces 150 and 152. Spool 46 is shaped to provide a driving interface, e.g., a channel, which extends from an opening provided by upper surface 150 to an opening provided by lower surface 152. A proximal portion of the driving interface is shaped to define a threaded portion 146 which may or may not be tapered. Threaded portion 146 of spool 46 is engageable by a threaded portion of a screwdriver head 92 of a screwdriver 90. Screwdriver 90 is coupled to a distal end of shaft 80. For some applications, shaft 80 rotates screwdriver 90. For other applications, shaft 80 is shaped so as to define a lumen for advancement therethrough of a screwdriver-rotation tool that facilitates rotation of screwdriver 90. Rotation of screwdriver 90 and screwdriver head 92 rotates spool 46, as the respective threaded portions of spool 46 and screwdriver head 92 engage. The cylindrical body portion of spool 46 is shaped to define one or more holes which function as respective coupling sites for coupling (e.g., looping through the one or more holes, or welding to spool 46 in the vicinity of the one or more holes) of any number of chords 74 to spool 46.

Lower surface 152 of spool 46 is shaped to define one or more (e.g., a plurality, as shown) recesses 154 which define structural barrier portions 155 of lower surface 152. It is to be noted that any suitable number of recesses 154 may be provided, e.g., between 1 and 10 recesses, circumferentially or otherwise, with respect to lower surface 152 of spool 46.

As shown, a locking mechanism 45 is disposed in communication with lower surface 152 of spool 46 and disposed in communication with at least in part to a lower surface of housing 49. Typically, a cap 44 maintains locking mechanism 45 in place with respect to lower surface 152 of spool 46 and lower surface of housing 49. For some applications, locking mechanism 45 is coupled, e.g., welded, to the lower surface of housing 49. Typically, locking mechanism 45 defines a mechanical element having a planar surface that defines slits. It is to be noted that the surface of locking mechanism 45 may also be curved, and not planar. Locking mechanism 45 is shaped to provide a protrusion 156 which projects out of a plane defined by the planar surface of the mechanical element. The slits of mechanism 45 define a depressible portion 128 that is disposed in communication with and extends toward protrusion 156. Depressible portion 128 is moveable in response to a force applied thereto typically by an elongate locking mechanism release rod 94 which slides through a lumen of screwdriver 90 and a torque-delivering tool that is coupled thereto.

It is to be noted that the planar, mechanical element of locking mechanism 45 is shown by way of illustration and not limitation and that any suitable mechanical element having or lacking a planar surface but shaped to define at least one protrusion may be used together with locking mechanism 45.

Cap 44 is provided that is shaped to define a planar surface and an annular wall having an upper surface thereof. The upper surface of the annular wall is coupled to, e.g., welded to, a lower surface provided by housing 49. The annular wall of cap 44 is shaped to define a recessed portion 144 of cap 44 that is in alignment with a recessed portion 142 of spool housing 49.

As shown, a distal end 96 of locking mechanism release rod 94 pushes distally on depressible portion 128 in order to unlock locking mechanism 45 from spool 46. Pushing depressible portion 128 by locking mechanism release rod 94 pushes distally protrusion 156 within recessed portion 142 of housing 49 and within recessed portion 144 of cap 44, which frees protrusion 156 from recesses 154 of spool 46. Once protrusion 156 is released from recesses 154 of spool 46, the physician is able to rotate spool 46 bidirectionally in order to adjust a tension of chord 74.

When the physician rotates spool 46 in the first rotational direction, chord 74 is pulled tight, and leaflet 14 is drawn toward adjustment mechanism 43 and toward anterior leaflet 12 of mitral valve 8.

In the resting state (i.e., prior to the rotation of spool 46 in order to adjust chord 74, following coupling of leaflet-engaging element 72 to leaflet 14) chord 74 is wrapped around spool 46 a few times (e.g., three times, by way of illustration and not limitation). This winding provides excess slack to chord 74 (in case portions 74 a and 74 b are coupled too tightly to leaflet 14). If the physician wishes to provide slack to member 74 or to any one of portion 74 a or 74 b, the physician unwinds a bit of the wrapped portion of member 74 from around spool 46 (e.g., by unwinding chord 74 a few times from around spool 46, or by unwinding chord 74 entirely from around spool 46 so that chord 74 slides freely through spool 46 within a channel provided therein). In order to accomplish such unwinding, the physician rotates spool 46 in a rotational direction in which it unwinds the wrapped portion of chord 74. Since chord 74 is looped through spool 46 in the channel provided therein, when chord 74 is unwound from spool 46, the physician can pull on one or both portions 74 a and 74 b so as to adjust, make even, or further slacken any one of or both portions 74 a and 74 b that extend from spool 46.

When the physician desires to pull tight chord 74, he or she effects rotation of spool 46 in a first rotational direction, i.e., the direction opposite the second rotational direction in which spool 46 is rotated during the unwinding of chord 74 from spool 46. Rotation of spool 46 in the first rotational direction winds chord 74 around spool 46, while rotation of spool 46 in a second rotational direction that is opposite the first rotational direction, unwinds the portion of longitudinal chord 74 from around spool 46.

FIG. 7 shows spool assembly 36 following the adjustment of chord 74 by rotating screwdriver 90 in the direction as indicated by the arrow, and the partial removal of screwdriver 90, in accordance with some applications of the present invention. As shown in the enlarged cross-sectional image of FIG. 7, successive portions of chord 74 are wrapped around spool 46. That is, chord 74 is wrapped more times around spool 46 following adjustment (e.g., an additional 4 times, as shown in FIG. 7), than prior to adjustment (FIG. 6). This pulls chord 74 from a slackened state (FIG. 6) to a taut state (FIG. 7) in order to adjust a length of chord 74 between adjustment mechanism 43 and the proximal end of chord 74 that is coupled to leaflet-engaging element 72. Additionally, this applying of tension to chord 74 adjusts a length between first and second implantation sites 5 and 7. Typically, chord 74 is adjusted while heart 2 is beating.

As shown, rod 94 is shaped so as to define a central lumen and a distal opening for passage therethrough of guide wire 40. Additionally, depressible portion 128 is shaped so as to provide an opening for passage of guide wire 40 therethrough. Guide wire 40 is looped around a distal looping element 55 of docking platform 54 of docking assembly 150. Following the adjusting of the tension and length of chord 74, screwdriver 90 is decoupled from spool 46 (e.g., by being unscrewed from threaded portion 146 of spool 46) and is advanced proximally together with rod 94 away from spool assembly 36, as shown in the enlarged, cross-sectional image of FIG. 7.

Following the decoupling of screwdriver 90 from spool 46 and the removal of screwdriver 90, guide wire 40 remains coupled to docking platform 54 and docking assembly 150. Guide wire 40 then facilitates subsequent advancement of screwdriver 90 or any other tool to access spool assembly 36 and/or to facilitate further adjustment of chord 74 beyond the initial adjustment. Guide wire 40 may remain chronically coupled to docking assembly 150 and may be accessible at a subcutaneous location of the patient, e.g., a port. For other applications, guide wire 40 is removed from docking assembly 150 when the physician determines that further adjustment of chord 74 is not needed. The physician removes guide wire 40 by pulling, from outside the body of the patient, one end of guide wire 40 so that guide wire 40 slides around element 55 and is unlooped therefrom. The physician continues to pull on the end of guide wire 40 until the second end of wire 40 is exposed and removed from the patient.

Following the removal of locking-mechanism release rod 94, depressible portion 128 is no longer depressed by distal end 96 of rod 94, and protrusion 156 returns within a recess 154 of spool 46 so as to lock spool 46 in place and restriction rotation thereof in either direction (FIG. 7).

Reference is now made to FIGS. 3-7. It is to be noted that spool assembly 36 is only coupled to docking assembly 150 following the coupling of leaflet-engaging element 72 to leaflet 14. This is done in order to reduce the strain on implantation site 5. Should spool assembly 36 be implanted at implantation site 5 prior to engaging leaflet 14 with leaflet-engaging element 72, more strain would be applied to implantation site 5 than if spool assembly 36 had been implanted following the coupling of leaflet-engaging element 72 to leaflet 14, as described herein. That is, the pulling force is applied in a downward direction from leaflet 14 toward implantation site 5 instead of from implantation site 5 upward toward leaflet 14.

FIG. 8 shows system 20 following the removal of the tool used to rotate spool 46 of spool assembly 36, in accordance with some applications of the present invention. As shown, chord 74 is pulled tight such that its length and tension are adjusted, and leaflet 14 is pulled and adjusted commensurate with the adjustment of chord 74. Guide wire 40 remains coupled to spool assembly 36 and to docking assembly 150, as shown, such that portions 40 a and 40 a′ extend from spool assembly 36. Guide wire 40 facilitates the reintroduction of the tool used to rotate spool 46, or of any other tool.

FIG. 9 shows system 20 following the removal of guide wire 40 from heart 2, in accordance with some applications of the present invention. As shown, the adjustment of chord 74 draws leaflets 12 and 14 together. It is to be noted that although leaflet-engaging element 72 is shown as engaging only leaflet 14, the scope of the present invention includes the engaging of both leaflets 12 and 14 by leaflet-engaging element 72.

FIG. 10 shows a system 220, as described hereinabove with reference to system 20, with the exception that implantation site 5 includes tissue of the wall of the ventricle at the base of papillary muscle 4 in a vicinity of the apex of the heart, in accordance with some applications of the present invention. Implantation site 5 is shown by way of illustration and not limitation, and as described hereinabove, site 5 may include any portion of tissue of heart 2. It is to be noted that although leaflet-engaging element 72 is shown as engaging only leaflet 14, the scope of the present invention includes the engaging of both leaflets 12 and 14 by leaflet-engaging element 72.

FIGS. 11-15 are schematic illustrations of a system 320 comprising a multiple-docking-station assembly 350 comprising a plurality of docking stations 56, in accordance with some applications of the present invention. Multiple-docking-station assembly 350 comprises a tissue anchor 50 and a docking platform 322 which supports two or more docking stations 56. Platform 322, as shown, supports three docking stations 56 a, 56 b, and 56 c, by way of illustration and not limitation. It is to be noted that platform 322 may support any number of docking stations 56. As shown, each docking station 56 a, 56 b, and 56 c is reversibly coupled to a respective guide wire 40 a, 40 b, and 40 c, in a manner as described hereinabove. Each docking station 56 a, 56 b, and 56 c facilitates coupling thereto of a respective spool assembly 36 a, 36 b, and 36 c, or any other tool or device which may be coupled to docking stations 56 a, 56 b, and 56 c.

As shown in FIGS. 11-13, first and second spool assemblies 36 a and 36 b are coupled via respective guide wires 40 a and 40 b to respective docking stations 56 a and 56 b. Each spool assembly 36 a and 36 b has a respective chord 74 aa and 74 bb extending therefrom (FIG. 13). For example (as shown in FIG. 12), the chord extending from spool assembly 36 a has portions 74 aa and 74 aa′ extending from spool assembly 36 a. Each chord 74 is coupled to a respective leaflet-engaging element 72. That is, chord 74 aa is coupled to leaflet-engaging element 72 a, and chord 74 bb is coupled to leaflet-engaging element 72 b (FIG. 13).

Each leaflet-engaging element 72 a and 72 b is coupled to leaflets 12 and 14, respectively, and then each spool assembly 36 a and 36 b is coupled to respective docking stations 56 a and 56 b, in a manner as described hereinabove. Chords 74 aa and 74 bb are then adjusted, as described hereinabove. Each chord 74 aa and 74 bb may be adjusted sequentially or simultaneously.

FIG. 13 shows chords 74 aa and 74 bb following their adjustment. The relative dispositions of leaflets 12 and 14 are adjusted in conjunction with the adjusting of chords 74 aa and 74 bb. Typically, leaflets 12 and 14 are drawn together to repair the heart valve.

As shown in FIG. 15, a third spool assembly 36 c may be coupled to docking station 56 c. Chord 74 c coupled thereto may be coupled to a third implantation site in heart 2 and subsequently adjusted. FIG. 15 shows third spool assembly 36 c coupled to docking station 56 c without the presence of the other spool assemblies 36 a and 36 b, by way of illustration and not limitation.

FIG. 16 shows a system 600 for repairing malpositioning of the wall of the ventricle of the patient, in accordance with respective applications of the present invention. System 600 treats a weakened state of heart 2 in which the wall of the left ventricle is malpositioned and weakened. As a result of the malpositioning of the wall of the heart, leaflets 12 and 14 of mitral valve 8 are malpositioned and are distanced from one another (not shown). In order to treat the malpositioning of the heart wall and thereby of leaflets 12 and 14, spool assembly 36 is implanted at a first portion 420 of heart tissue which faces and surrounds the left ventricle of heart 2. First implantation site 5 thus comprises first portion 420 of heart tissue. It is to be noted that first implantation site 5 is at the base of the papillary muscle by way of illustration and not limitation, and that first implantation site 5 may be at a portion of the wall of the heart in a vicinity of the apex of the heart, or at papillary muscle 4. For some applications in which system 600 treats malpositioning of the heart, docking assembly 350 and spool assembly 36 are implanted externally to the ventricle, and chord 74 extends through cardiac tissue and into the ventricle toward implantation site 7.

Spool assembly 36 is implanted via docking assembly 150 at site 5 in a manner as described hereinabove with reference to FIGS. 3-6. As shown, the free ends of chord 74 are coupled to a second portion 422 of heart tissue which faces and surrounds the left ventricle of heart 2. Second implantation site 7 thus comprises second portion 422 of heart tissue, e.g., at the septum, by way of illustration and not limitation. The free ends of longitudinal chord 74 are coupled to the heart tissue using any suitable attachment means 602, e.g., sutures, knotting, or tissue anchors such as helical anchors. Spool 46 of adjustment mechanism 43 is rotated, as described hereinabove, thereby pulling tight chord 74 and thereby reducing a length of chord 74 between first and second implantation sites 5 and 7. In response to the pulling of chord 74, first and second portions 420 and 422 of the heart tissue are pulled toward one another, and a length of chord 74 is adjusted. Consequently, the dimensions of the heart wall are restored to physiological dimensions, and leaflets 12 and 14 are drawn toward one another.

FIG. 17 shows a system 610 for adjusting both malpositioning of a heart wall of heart 2, and a relative disposition of leaflet 12, in accordance with some applications of the present invention. Multiple-docking-station assembly 350 is implanted at implantation site 5, i.e., a portion of tissue of a heart wall of heart 2 in a vicinity of the apex of heart 2. It is to be noted that implantation site 5 may include any portion of tissue of heart 2, e.g., a portion of tissue at the base of papillary muscle 4, a portion of tissue of papillary muscle 4, or a portion of the free wall of the ventricle. As described hereinabove, first spool assembly 36 a is coupled to docking station 56 a and adjusts a length of chord 74 aa in order to adjust a distance between implantation sites 5 and 7. Second spool assembly 36 b is coupled to docking station 56 b and adjusts a length of chord 74 bb in order to adjust a distance between implantation site 5 a third implantation site 9 (e.g., leaflet 12, as shown). As described hereinabove, chords 74 aa and 74 bb may be adjusted simultaneously or sequentially. Following the adjusting, implantation sites 7 and 9 are drawn toward multiple-docking-station assembly 350 at implantation site 5. Consequently, the dimensions of the heart wall are restored to physiological dimensions, and leaflets 12 and 14 are drawn toward one another. It is to be noted that although leaflet-engaging element 72 is shown as engaging only leaflet 12, the scope of the present invention includes the engaging of both leaflets 12 and 14 by leaflet-engaging element 72.

It is to be further noted that the scope of the present invention includes the coupling of a third spool assembly to docking station 56 c coupled to chord 74 c. For such applications, the free end of chord 74 c may be coupled to a different portion of cardiac tissue, e.g., leaflet 14.

FIG. 18 is a schematic illustration of a system 800 for adjusting a distance between two portions of a heart wall of the left ventricle of the patient, in accordance with some applications of the present invention. System 800 comprises a tensioning device 802 coupled at a first end thereof to spool assembly 36 at docking assembly 150. In a manner as described hereinabove, spool assembly 36 is implanted at first implantation site 5 in a first portion of tissue of the heart wall that faces and surrounds the ventricular lumen. The free end of tensioning device 802 is attached at second implantation site 7 to a second portion of tissue of the heart wall that faces and surrounds the ventricular lumen. The free end of tensioning device 802 is implanted in heart tissue using a helical anchor by way of illustration and not limitation. For example, the free end of tensioning device 802 may be coupled to second implantation site 7 using sutures, knots, or any tissue anchor known in the art.

Tensioning device 802 comprises a flexible material, e.g., ePTFE or nitinol, and is shaped to define a coiled portion 806 that has a length of between 20 mm and 50 mm and a diameter of between 0.5 mm and 3.0 mm Tensioning device 802 comprises respective wire/suture portions 804 on either side of coiled portion 806. For such an application, the suture portion 804 that is between spool assembly 36 and coiled portion 806 comprises portions 74 a and 74 b of chord 74.

As described hereinabove, spool 46 of adjustment mechanism 43 is rotated in order to adjust a distance between first and second implantation sites 5 and 7. As spool 46 is rotated in a first direction thereof, successive portions of chord 74 of suture portion 804 that is disposed adjacently to spool assembly 36 are wrapped around spool 46. Tensioning device 802 is tightened and shortened in response to the wrapping of portion 804 around spool 46. As device 802 is tightened, a force is applied to coiled portion 806 of tensioning device 802. Coiled portion 806 applies a supplemental puling force to help pull the opposing first and second portions of the ventricle wall toward one another. Consequently, the dimensions of the heart wall are restored to physiological dimensions, and leaflets 12 and 14 are drawn toward one another.

Reference is made to FIGS. 16-18. It is to be noted that the scope of the present invention includes the use of systems 600, 610, and 800 for adjusting a distance between any two portions of the heart and not just opposing portions, as described hereinabove. For example, first and second implantation sites 5 and 7 may be on the same side, e.g., the septum, of the wall of the heart.

Reference is now made to FIG. 19, which is a schematic illustration of a system 960 for drawing together leaflets 12 and 14 of mitral valve 8 of the patient, in accordance with some applications of the present invention. Spool assembly 36 is implanted via docking assembly 150 in first implantation site 5 at papillary muscle 4 of the left ventricle by way of illustration and not limitation. For example, spool assembly 36 may be implanted in a portion of the heart wall of the ventricle, e.g., the base of the papillary muscle. First and second portions 74 a and 74 b of chord 74 are coupled (e.g., sutured, anchored, clipped, or locked in place with a crimping bead 918, as shown) to leaflet 12 at an implantation site 902. It is to be noted that portions 74 a and 74 b may be coupled to leaflets 12 and 14, respectively, using leaflet-engaging elements 72 as described hereinabove.

As described hereinabove, spool 46 of adjustment mechanism 43 is rotated in order to adjust a length of portions 74 a and 74 b of chord 74. Portions 74 a and 74 b are pulled tight in response to rotation of spool 46 in a first direction thereof. In response to the pulling of portions 74 a and 74 b, leaflets 12 and 14 are pulled toward one another in order to restore coaptation to valve 8.

It is to be noted that system 960 may be used on the tricuspid valve.

System 960 further comprises at least one bead 940 that is threaded over portions 74 a and 74 b of chord 74. The surgeon adjusts the position of the bead along the portions 74 a and 74 b in order to set the degree to which portions 74 a and 74 b are free to move with respect to one another. In general, as bead 940 is positioned closer to valve 8, portions 74 a and 74 b are more constrained in their motion with respect to one another, and leaflets 12 and 14 are drawn closer together. For some applications of the present invention, bead 940 comprises a fixation mechanism (e.g., a crimping mechanism), which is configured to fix the bead to portions 74 a and 74 b of chord 74 once bead 940 has been positioned at a desire location along portions 74 a and 74 b.

FIG. 20 shows a system 980 that is similar to system 960 as described with reference to FIG. 19, with the exception that bead 940 is pulled by the operating physician to the ventricular surface of a middle portion of valve 8, in accordance with some applications of the present invention. Such pulling of bead 940 to the ventricular surface creates a bridge between leaflets 12 and 14, e.g., as an Alfieri stitch, or edge-to-edge repair. Portions 74 a and 74 b are then adjusted in order to pull together the middle portion of mitral valve 8, as shown in Section A-A. The firm coupling of leaflets 12 and 14 prevents prolapsing of leaflets 12 and 14, facilitates coaptation of leaflets 12 and 14, and creates orifices 962 and 964 (section A-A) in mitral valve 8 so as to facilitate blood flow from the atrium to the ventricle. Additionally, the adjusting of portions 74 a and 74 b of chord 74 draws downward leaflets 12 and 14 and adjusts chord 74 such that it functions as an artificial chordea tendinea.

Reference is now made to FIGS. 19 and 20. It is to be noted that although docking assembly 150 is shown, multiple-docking-station assembly 350 as described hereinabove, may be implanted at implantation site 5. For such an application, two or more spool assemblies 36 may be coupled to multiple-docking-station assembly 350, and any number of chords 74 extending from each spool assembly 36 may be coupled to leaflets 12 and 14 at any suitable location thereof. The lengths of chords 74 are then adjusted by spool assemblies 36 in order to pull leaflets 12 and 14 together.

Reference is now made to FIG. 21, which is a schematic illustration of a system 1000 comprising docking assembly 150 for implantation at an implantation site 5 a that includes an annulus 1100 of a cardiac valve of the patient, in accordance with some applications of the present invention. It is to be noted that the mitral valve is shown by way of illustration and not limitation, and that system 1000 can be used on any other cardiac valve of the patient, e.g., the tricuspid valve, the pulmonary valve, and the aortic valve. System 1000 comprises docking assembly 150 and the guide member coupled thereto (e.g., guide wire 40), as described hereinabove with reference to FIGS. 1-2.

For some applications in which docking assembly 150 is implanted at the annulus of the cardiac valve, implant 42 configured to be coupled to docking assembly 150 comprises an annuloplasty ring structure (e.g., a full annuloplasty ring or a partial annuloplasty ring). Typically, the annuloplasty ring structure comprises adjustment mechanism 43. It is to be noted, however, that the annuloplasty ring structure configured to be coupled to docking assembly 150 may be provided independently of adjustment mechanism 43. That is, any suitable annuloplasty ring structure may be coupled to docking assembly 150. For such applications, the annuloplasty ring structure is slid along guide wire 40 toward docking assembly 150.

For other applications in which docking assembly 150 is implanted at the annulus of the cardiac valve, implant 42 configured to be coupled to docking assembly 150 comprises a prosthetic valve or a support structure for coupling a prosthetic valve thereto. For some applications, the support structure comprises adjustment mechanism 43. It is to be noted, however, that the support structure configured to be coupled to docking assembly 150 may be provided independently of adjustment mechanism 43. That is, any suitable support structure or prosthetic valve may be coupled to docking assembly 150. For such applications, the support structure or prosthetic valve is slid along guide wire 40 toward docking assembly 150.

Reference is made to FIG. 22, which is a schematic illustration of system 1000 being used to facilitate implantation of implant 42, comprising an annuloplasty ring 1120, at annulus 1100 of a cardiac valve, in accordance with some applications of the invention. It is to be noted that the mitral valve is shown by way of illustration and not limitation, and that system 1000 can be used on any other cardiac valve of the patient, e.g., the tricuspid valve, the pulmonary valve, and the aortic valve. It is to be noted that annuloplasty ring 1120 is shown as a partial annuloplasty ring by way of illustration and not limitation, and that annuloplasty ring 1120 may comprise a full annuloplasty ring. Docking assembly 150 is advanced to the annulus, and tissue anchor 50 is anchored to tissue in the vicinity of the annulus (e.g., to tissue of the annulus). For applications in which tissue anchor 50 comprises a helical tissue anchor, the anchor is typically coupled to the tissue by rotating the entire docking assembly 150 (e.g., using a delivery tool, such as delivery tool 30, described hereinabove with reference to FIGS. 1-2, mutatis mutandis). As described hereinabove (e.g., with reference to FIG. 2), a guide member (e.g., guide wire 40) is left behind, coupled to docking assembly 150 (e.g., to docking station 56 thereof).

Subsequently, and as shown in FIG. 22, annuloplasty ring 1120 is advanced along guide wire 40 toward annulus 1100 and docking assembly 150. Typically, annuloplasty ring 1120 is shaped to define a channel therethrough (e.g., between an upper surface and a lower surface of the annuloplasty ring), within which guide wire 40 is configured to be disposed, and the annuloplasty ring is slid over the guide wire. For some applications, and as shown in FIG. 22, annuloplasty ring 1120 comprises an adjustable annuloplasty ring that comprises an adjustment mechanism 1143, configured to adjust the annuloplasty ring (e.g., as described hereinbelow). For some such applications, adjustment mechanism 1143 is shaped to define the channel within which guide wire 40 is configured to be disposed.

Typically, adjustment mechanism 1143 comprises adjustment mechanism 43 and/or spool assembly 36, described hereinabove. Further typically, annuloplasty ring 1120 comprises a sleeve 1126 that defines a lumen therethrough, and a flexible longitudinal member 1130, disposed at least in part within the lumen of the sleeve, and adjustment mechanism 1143 is configured to adjust the length of the sleeve (e.g., the diameter of the annuloplasty ring) by adjusting the length of the flexible longitudinal member. For some applications, flexible longitudinal member 1130 is coupled to and adjusted by adjustment mechanism 1143, in a similar manner to that in which chord 74 is coupled to and adjusted by adjustment mechanism 43, described hereinabove.

Once annuloplasty ring 1120 reaches docking assembly 150, the annuloplasty ring is locked to the docking assembly as described hereinabove (e.g., with reference to FIG. 6), mutatis mutandis. That is, a coupling defined by the annuloplasty ring is locked to a coupling defined by the docking assembly, typically by the couplings being pushed toward and/or into each other.

For some applications, additional anchors are subsequently used to couple other portions of annuloplasty ring 1120 to other portions of tissue in the vicinity of annulus 1100. For example, and as shown in FIG. 22, annuloplasty ring 1120 may comprise a partial annuloplasty ring that comprises sleeve 1126, and successive portions of sleeve 1126 may be placed on annulus 1100, and anchored to the annulus using a plurality of successive anchors 1140, deployed using a deployment manipulator 1142, from within the lumen of the sleeve, through the wall of the sleeve, and into the annulus. For some such applications, docking assembly 150 is used to guide and anchor a first portion of the annuloplasty ring to a first anchoring site of the annulus, and successive anchors 1140 are subsequently used to anchor other portions of the annuloplasty ring.

For some applications, a plurality of docking assemblies 150 and a plurality of guide wires 40 are used to advance and lock a plurality of portions of annuloplasty ring 1120 to the tissue. For some such applications, annuloplasty ring comprises a plurality of adjustment mechanisms 1143 disposed around the length of sleeve 1126 (e.g., to adjust the length of different portions of the sleeve), and each of the adjustment mechanisms is advanced over a respective guide wire 40 and locked to a respective docking station of a respective docking assembly.

It is to be noted that the locking of annuloplasty ring 1120 to docking assembly 150 is performed suturelessly.

For some applications of the present invention, systems 20, 220, 320, 600, 610, 800, 960, 980, and 1000 are used to treat an atrioventricular valve other than the mitral valve, i.e., the tricuspid valve. For these applications, systems 20, 220, 320, 600, 610, 800, 960, 980, and 1000 described hereinabove as being placed in the left ventricle are instead placed in the right ventricle.

It is to be noted that the scope of the present invention includes the use of systems 20, 220, 320, 600, 610, 800, 960, 980, and 1000 on other cardiac valves, such as the pulmonary valve or the aortic valve.

It is to be further noted that the scope of the present invention includes the use of systems 20, 220, 320, 600, 610, 800, 960, 980, and 1000 on other tissue other than cardiac tissue, e.g., gastric tissue or any other suitable tissue or organ.

For some applications, techniques described herein are practiced in combination with techniques described in one or more of the references cited in the Background section of the present patent application.

Additionally, the scope of the present invention includes applications described in the following applications, which are incorporated herein by reference. In an application, techniques and apparatus described in one or more of the following applications are combined with techniques and apparatus described herein:

-   -   PCT Publication WO 2006/097931 to Gross et al., entitled,         “Mitral Valve treatment techniques,” filed Mar. 15, 2006;     -   U.S. Provisional Patent Application 60/873,075 to Gross et al.,         entitled, “Mitral valve closure techniques,” filed Dec. 5, 2006;     -   U.S. Provisional Patent Application 60/902,146 to Gross et al.,         entitled, “Mitral valve closure techniques,” filed on Feb. 16,         2007;     -   U.S. Provisional Patent Application 61/001,013 to Gross et al.,         entitled, “Segmented ring placement,” filed Oct. 29, 2007;     -   PCT Patent Application PCT/IL07/001503 to Gross et al.,         entitled, “Segmented ring placement,” filed on Dec. 5, 2007,         which published as WO 2008/068756;     -   U.S. patent application Ser. No. 11/950,930 to Gross et al.,         entitled, “Segmented ring placement,” filed on Dec. 5, 2007,         which published as US Patent Application Publication         2008/0262609 (now U.S. Pat. No. 8,926,695);     -   U.S. Provisional Patent Application 61/132,295 to Gross et al.,         entitled, “Annuloplasty devices and methods of delivery         therefor,” filed on Jun. 16, 2008;     -   U.S. patent application Ser. No. 12/341,960 to Cabiri, entitled,         “Adjustable partial annuloplasty ring and mechanism therefor,”         filed on Dec. 22, 2008, which published as 2010/0161047 (now         U.S. Pat. No. 8,241,351);     -   U.S. Provisional Patent Application 61/207,908 to Miller et al.,         entitled, “Actively-engageable movement-restriction mechanism         for use with an annuloplasty structure,” filed on Feb. 17, 2009;     -   U.S. patent application Ser. No. 12/435,291 to Maisano et al.,         entitled, “Adjustable repair chords and spool mechanism         therefor,” filed on May 4, 2009, which published as 2010/0161041         (now U.S. Pat. No. 8,147,542);     -   U.S. patent application Ser. No. 12/437,103 to Zipory et al.,         entitled, “Annuloplasty ring with intra-ring anchoring,” filed         on May 7, 2009, which published as 2010/0286767 (now U.S. Pat.         No. 8,715,342);     -   PCT Patent Application PCT/IL2009/000593 to Gross et al.,         entitled, “Annuloplasty devices and methods of delivery         therefor,” filed on Jun. 15, 2009, which published as WO         2010/004546;     -   U.S. patent application Ser. No. 12/548,991 to Maisano et al.,         entitled, “Implantation of repair chords in the heart,” filed on         Aug. 27, 2009, which published as 2010/0161042 (now U.S. Pat.         No. 8,808,368);     -   U.S. patent application Ser. No. 12/608,316 to Miller et al.,         entitled, “Tissue anchor for annuloplasty ring,” filed on Oct.         29, 2009, which published as 2011/0106247 (now U.S. Pat. No.         8,277,502);     -   PCT Patent Application PCT/IL2009/001209 to Cabin et al.,         entitled, “Adjustable annuloplasty devices and mechanisms         therefor,” filed on Dec. 22, 2009, which published as WO         2010/073246;     -   U.S. patent application Ser. No. 12/689,635 to Zipory et al.,         entitled, “Over-wire rotation tool,” filed on Jan. 19, 2010,         which published as 2010/0280604 (now U.S. Pat. No. 8,545,553);     -   U.S. patent application Ser. No. 12/689,693 to Hammer et al.,         entitled, “Application Deployment techniques for annuloplasty         ring,” filed on Jan. 19, 2010, which published as 2010/0280605         (now U.S. Pat. No. 8,911,494);     -   U.S. patent application Ser. No. 12/706,868 to Miller et al.,         entitled, “Actively-engageable movement-restriction mechanism         for use with an annuloplasty structure,” filed on Feb. 17, 2010,         which published as 2010/0211166 (now U.S. Pat. No. 8,353,956);         and/or     -   U.S. patent application Ser. No. 12/795,026 to Miller et al.,         entitled, “Apparatus for guide-wire based advancement of a         rotation assembly,” filed on Jun. 7, 2010, which published as         2011/0106245 (now U.S. Pat. No. 8,940,042).

It will be appreciated by persons skilled in the art that the present invention is not limited to what has been particularly shown and described hereinabove. Rather, the scope of the present invention includes both combinations and subcombinations of the various features described hereinabove, as well as variations and modifications thereof that are not in the prior art, which would occur to persons skilled in the art upon reading the foregoing description. 

1. Apparatus for use with a heart of a subject, the apparatus comprising: a tissue-engaging element having a distal portion configured to engage a portion of tissue of the heart; a guide member reversibly coupled to the tissue-engaging element; an artificial chorda tendinea having a distal end and a proximal end, at least the distal end being slidably coupled to the guide member; and a tool, slidable along the guide member distally toward the tissue-engaging element while (i) the tool is coupled to at least the distal end of the chorda tendinea, and (ii) the guide member is coupled to the tissue-engaging element, such that sliding of the tool along the guide member distally toward the tissue-engaging element while (i) the tool is coupled to at least the distal end of the chorda tendinea, and (ii) the guide member is coupled to the tissue-engaging element, slides at least the distal end of the chorda tendinea toward the tissue-engaging element.
 2. The apparatus according to claim 1, wherein the tool is configured to couple the distal end of the chorda tendinea to the tissue-engaging element.
 3. The apparatus according to claim 1, wherein the tool is configured to decouple the guide member from the tissue-engaging element.
 4. The apparatus according to claim 1, further comprising a cap that is shaped to define an opening through which the guide member is slidable, wherein at least the distal end of the chorda tendinea is slidably coupled to the guide member via the cap.
 5. The apparatus according to claim 1, wherein the tool is configured to couple a proximal end of the chorda tendinea to a valve leaflet of the heart.
 6. The apparatus according to claim 5, further comprising a leaflet-engaging element coupled to a proximal end of the chorda tendinea, and wherein: the tool comprises a holder, reversibly coupled to the leaflet-engaging element, the tool is configured to couple the proximal end of the chorda tendinea to the valve leaflet by coupling the leaflet-engaging element to the leaflet.
 7. The apparatus according to claim 1, further comprising an adjustment mechanism that is coupled to the distal end of the chorda tendinea, and is configured to adjust a tension of the chorda tendinea upon actuation of the adjustment mechanism.
 8. The apparatus according to claim 7, wherein: the tool is coupled to a proximal end of the chorda tendinea, and is configured to couple the proximal end of the chorda tendinea to a valve leaflet of the heart, and while (i) the tool is coupled to the distal end of the chorda tendinea, and to the proximal end of the chorda tendinea, and (ii) the chorda tendinea is entirely within the heart, the tool is configured to adjust a distance between the distal end of the chorda tendinea and the proximal end of the chorda tendinea, independently of actuation of the adjustment mechanism.
 9. The apparatus according to claim 7, wherein the tool is reversibly couplable to the distal end of the chorda tendinea by being reversibly coupled to the adjustment mechanism.
 10. The apparatus according to claim 9, wherein the tool is configured to actuate the adjustment mechanism.
 11. The apparatus according to claim 7, wherein the adjustment mechanism: comprises a rotatable structure disposed within a housing, and coupled to the chorda tendinea, and is configured to adjust the tension of the chorda tendinea by rotation of the rotatable structure with respect to the housing.
 12. The apparatus according to claim 11, wherein the rotatable structure is rotatable bidirectionally with respect to the housing.
 13. The apparatus according to claim 11, wherein the adjustment mechanism comprises a locking mechanism configured to reversibly inhibit rotation of the rotatable structure with respect to the housing.
 14. The apparatus according to claim 1, wherein the tool is configured to couple the distal end of the chorda tendinea to the tissue-engaging element, and to subsequently decouple the guide member from the tissue-engaging element while the chorda tendinea remains coupled to the tissue-engaging element.
 15. The apparatus according to claim 1, wherein the tool is a chorda-delivery tool, and the apparatus further comprises a separate delivery tool, configured to advance the tissue-engaging element to the heart, and to secure the tissue-engaging element to the portion of tissue.
 16. The apparatus according to claim 15, further comprising a sheath that is transluminally and transseptally advanceable into a left atrium of the heart, wherein: the separate delivery tool is configured to advance the tissue-engaging element, coupled to the guide member, through the sheath to the heart, subsequent to securing the tissue-engaging element to the portion of the tissue, the separate delivery tool is disengageable from the tissue-engaging element and removable from the subject, subsequent to removal of the separate delivery tool from the subject, the chorda-delivery tool is slidable, within the sheath, along the guide member distally toward the tissue-engaging element, while (i) the tool is coupled to at least the distal end of the chorda tendinea, and (ii) the guide member remains coupled to the tissue-engaging element.
 17. The apparatus according to claim 1, wherein: the portion of tissue faces a ventricle of the heart, the distal portion of the tissue-engaging element is configured to engage the portion of tissue that faces the ventricle of the heart, and the tool is slidable along the guide member distally toward the tissue-engaging element while (i) the tool is coupled to at least the distal end of the chorda tendinea, and (ii) the guide member is coupled to the tissue-engaging element, such that sliding of the tool along the guide member distally toward the tissue-engaging element while (i) the tool is coupled to at least the distal end of the chorda tendinea, (ii) the guide member is coupled to the tissue-engaging element, and (iii) the distal portion of the tissue-engaging element is engaged with the portion of tissue that faces the ventricle of the heart, slides at least the distal end of the chorda tendinea toward the portion of tissue that faces the ventricle of the heart.
 18. The apparatus according to claim 17, wherein: the portion of tissue is a papillary muscle of the heart, the distal portion of the tissue-engaging element is configured to engage the papillary muscle, and the tool is slidable along the guide member distally toward the tissue-engaging element while (i) the tool is coupled to at least the distal end of the chorda tendinea, and (ii) the guide member is coupled to the tissue-engaging element, such that sliding of the tool along the guide member distally toward the tissue-engaging element while (i) the tool is coupled to at least the distal end of the chorda tendinea, (ii) the guide member is coupled to the tissue-engaging element, and (iii) the distal portion of the tissue-engaging element is engaged with the papillary muscle, slides at least the distal end of the chorda tendinea toward the papillary muscle.
 19. The apparatus according to claim 1, wherein the tissue-engaging element is an anchor, and the distal portion of the tissue-engaging element is helical and configured to be corkscrewed into the portion of tissue.
 20. The apparatus according to claim 1, further comprising a sheath that is transluminally and transseptally advanceable into a left atrium of the heart, wherein the tool is slidable, within the sheath, along the guide member distally toward the tissue-engaging element. 